Substance P concentration and history of headache in relation to postlumbar puncture headache: towards prevention

Nebulized dexmedetomidine versus neostigmine/atropine for treating post-dural puncture headache after cesarean section: a double-blind randomized controlled trial

BACKGROUND

Post-dural puncture headache (PDPH) is one of the most common complications of neuraxial anesthesia after an accidental dural puncture. This study aimed to test non-interventional alternatives to treat PDPH. Our goals were to compare the effectiveness of nebulized dexmedetomidine (DEX) versus neostigmine/atropine in the conservative management of PDPH.

METHODS

A randomized double-blind controlled study of ninety (90) women divided into three equal groups: group C (given nebulization of saline 0.9% placebo in four mL), group N (given nebulization of 20 µ/kg neostigmine and 10 µ/kg atropine diluted in four mL normal saline), and group D (given nebulization of dexmedetomidine 1 µg/kg diluted in four mL normal saline). Nebulization was done twice daily for three days, and a Visual Analogue Scale pain score (VAS) was recorded for seventy-two hours after the intervention for the three groups with a VAS Score equal or less than three being the cutoff value.

RESULTS

VAS was significantly decreased in dexmedetomidine, and neostigmine/atropine groups compared to the control group at six hours (median VAS: 5, 2, and 2 for groups C, N, and D respectively [P=0.001]). There was a significant difference in VAS trends between the three groups (at six, twelve, twenty-four, thirty-six, and forty-eight hours [P=0.001], and at seventy-two hours [P=0.003]). No patients in group D, but one patient in group N and seven patients in group C needed an epidural blood patch.

CONCLUSIONS

Nebulized dexmedetomidine and neostigmine/atropine had a rapid effect on relieving PDPH after cesarean section.

Long-term complications of unintentional dural puncture during labor epidural analgesia: a case-control study

INTRODUCTION

Epidural analgesia is the preferred method to manage pain during labor and delivery. The insertion of the epidural catheter can be complicated by unintentional dural puncture that may result in postdural puncture headache. There is limited evidence on the long-term implications of this complication. We sought to investigate if women who sustained a dural puncture have a higher risk of developing chronic headache, low back pain and visual or auditory impairment.

METHODS

We conducted a 1:1 case-control study with women who delivered at our institution from January 2015 to December 2019. Cases were women who received epidural analgesia and sustained an unintentional dural puncture, and controls were women who received epidural analgesia but did not sustain such complication. We matched cases and controls for date of delivery, age, and body mass index. All women completed an online survey with validated questionnaires for diagnosis of chronic headache and chronic back pain. We used dichotomic (yes/no) questions to look for the presence of chronic visual and auditory impairment.

RESULTS

Sixty-three case-control pairs were studied. Women who sustained a dural puncture during their epidural catheter insertion had a higher risk of developing chronic headache (14.3%, vs 4.8%, p=0.057, adjusted OR (AOR): 3.67 (95% CI 1.05 to 12.82)) and chronic back pain (39.7% vs 19.1%, p=0.009, AOR: 2.67 (95% CI 1.25 to 5.72)) than women who did not sustain a dural puncture. The incidence of chronic auditory impairment was also higher in the dural puncture group (14.3% vs 1.6%, p=0.01, AOR: 9.98 (95% CI 1.21 to 82.62)).

CONCLUSIONS

An unintentional dural puncture during epidural catheter insertion in parturients is associated with increased risk of chronic headache, back pain and auditory impairment.

Aminophylline for Prevention and/or Treatment of Post-Dural Puncture Headache: A Systematic Review and Meta-Analysis Study Protocol

Objectives

Post-dural Puncture Headache (PDPH) is prevalent among individuals undergoing lumbar punctures. The non-invasive effect of some drugs, such as aminophylline on PDPH has been investigated in several clinical studies. As there is no comprehensive systematic review and meta-analysis about the preventive and therapeutic effects of aminophylline on PDPH in the literature, the clinical effectiveness of this drug on the prevention and/or treatment of PDPH will be assessed in this study.

Methods

PubMed/MEDLINE, Embase, WoS (Clarivate Analytics), the Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL Complete, Scopus, and Google Scholar as electronic databases will be precisely searched for clinical studies that assessed the effect of aminophylline on PDPH. Studies between 01-01-1980 and 30-06-2020 will be evaluated in this study, and there will not be any language restrictions. Contradictions between the reviewers within any phase of the study (screening, selecting, quality assessment, and data extraction) will be resolved by consensus; in case of unsolved disagreements, a third reviewer will eventually decide. The combination method will be applied according to the methodological resemblance in the selected articles using the Random Effect Model or the Fixed Effect Model. Also, for the included articles, forest plots will be drawn. For assessing statistical heterogeneity, the I² statistic and the Q-statistic test will be applied. In addition, funnel plots will be used for assessing non-significant study effects and potential reporting bias. Furthermore, Egger’s and Begg’s tests will be done, and publication bias will be indicated by significant findings (P < 0.05).

Conclusions

It is expected that the results of this study will be of benefit to researchers and clinicians for managing PDPH, and will be reported in conferences and publications.

Downregulation of CSF-derived miRNAs miR-142-3p and miR-17-5p may be associated with post-dural puncture headache in pregnant women upon spinal anaesthesia

Background

Postdural puncture headache (PDPH) develops due to puncture of the dura mater. The risk factors that influence PDPH incidence are Body Mass Index (BMI), sex, spinal needle type, history of headache, and loss of Cerebrospinal fluid (CSF) volume, yet there is no consensus on these risk factors. The pathophysiology of PDPH is poorly understood. The molecular pathways that may lead to PDPH are unknown. In this study, CSF – derived microRNAs (miRNAs) were investigated for their potential to predispose to PDPH in a population of pregnant women.

Methods

Pregnant women going under cesarean section via spinal anesthesia were included in the study with the criteria of the subjects presenting American Society of Anesthesiologists (ASA) physical status I. Patients were classified into two groups as with PDPH (n = 10) and without PDPH (n = 12) based on International Headache Society’s PDPH definition. CSF-derived microRNAs were investigated for their differential expression levels in PDPH patients compared with the healthy controls using microfluidic gene expression platform.

Results

Out of seventy-six miRNAs, two miRNAs, namely miR-142-3p and miR-17-5p, were significantly downregulated in PDPH patients (Mann-Whitney U test, p < 0,05). BMI and age did not influence PDPH occurrence. The mean visual analogue scale (VAS) of the PDPH patients was 6,8 out of 10.

Conclusion

We have shown that downregulation of miR-142-3p and miR-17-5p may predispose pregnant women to PDPH upon spinal anesthesia. However, which genes are targeted by miR-142-3p and miR-17-5p-mediated effect on PDPH remains to be elucidated.

Correlates of post-dural puncture headache and efficacy of different treatment options: a monocentric retrospective study

Background:

Post-dural puncture headache (PDPH) is a severe positional headache that appears usually within 72 hours after inadvertent dural puncture, secondary to cerebrospinal fluid leakage. It is treated first by conservative treatment (including bed rest, hydration, caffeine and simple analgesia) and then by invasive procedures such as blood patch. This study aims to evaluate factors associated with PDPH among a sample of Lebanese patients and assess the rate of success of different treatment modalities administered in a specific sequence: conservative treatment first, then ultrasound-guided bilateral greater occipital nerve block (GONB) if failure of conservative treatment and finally epidural blood patch (EBP) if failure of GONB.

Methods:

A retrospective case–control study was conducted between January 2015 and December 2019 in the Notre-Dame des Secours University Hospital. Out of a total of 10,051 procedures, 18 cases were diagnosed with PDPH and were matched based on gender, age and procedure type to a control group of patients who did not develop PDPH randomly selected (72 patients).

Results:

Higher body mass index (adjusted odds ratio (ORa) = 0.77) was significantly associated with lower odds of PDPH, whereas the presence of previous chronic headache (ORa = 5.56) was significantly associated with higher odds of PDPH. Seven out of 18 (38.89%) had their pain symptoms/headache resolved on conservative treatment. Out of the remaining 11 patients, 6 (33.33%) had their symptoms resolved on GONB with a significant decrease in the pain score 48 hours after GONB compared to baseline (5.55 vs 9.73; p = 0.007). Five patients (27.78%) had their symptoms resolved using a blood patch, with a significant decrease in the pain score after blood patch compared to baseline (3.00 vs 9.80; p = 0.041).

Conclusion:

Our preliminary data suggest that ultrasound-guided GONB is a minimally risky and efficacious technique for those who fail to respond to conservative treatment.

Magnetic resonance imaging of cerebrospinal fluid spread in the epidural space and postdural puncture headache in obstetrics: A proof-of-concept study

BACKGROUND

Currently, performing an epidural blood patch (EBP) for postdural puncture headache (PDPH) remains a subjective clinical decision. An evidence-based protocol may be of value in identifying women at high risk of developing a severe PDPH.

OBJECTIVE

To investigate a potential correlation between the extent of CSF spread in the epidural space, as noted on Magnetic Resonance Imaging (MRI), and the likelihood of development of severe PDPH in obstetric patients.

DESIGN

A prospective double-blind quasi-observational study.

SETTING

Eight tertiary obstetric units, from NHS hospitals.

PATIENTS

Parturients with accidental dural puncture (ADP) underwent T1 and T2-weighted MRI scans of the brain and lumbar spine within 48 h after delivery. All women were followed up, daily, for 1 week.

MAIN OUTCOME MEASURES

For each woman, a PDPH severity score was calculated using a four-point Verbal Reporting Scale (none = 0, mild = 1, moderate = 2, severe = 3), with additional points awarded for visual, auditory and emetic symptoms. MRIs were reported by a neuroradiologist, blind to the patient details, using a predefined MRI score.

RESULTS

Twenty-two parturients were recruited; 86% (n=19) developed PDPH and 10 of these (53%) required an EBP. The median (range) time for the onset of PDPH was 24 (4 to 126) hours. The median (range) cumulative PDPH severity score was 10 (0 to 21), whereas, the median (range) MRI score was 2.5 (0 to 12). Spearman (rs) analysis identified a significant positive correlation (rs = 0.46; P = 0.024) between cumulative PDPH severity and MRI scores. Of all the radiological features identified in an MRI (lumbar dural shift, caudal brain displacement, epidural or intrathecal blood), the presence of intrathecal blood was most strongly correlated with PDPH severity (P = 0.043).

CONCLUSION

Following an ADP, the extent of CSF spread in the epidural space correlates with the severity of subsequent PDPH.

CLINICAL TRIAL NUMBER AND REGISTRY URL

ISRCTN14959004, https://www.isrctn.com/.

Occurrence of postdural puncture headache-A randomized controlled trial comparing 22G Sprotte and Quincke

OBJECTIVE

To assess the incidence of postdural puncture headache (PDPH) using 22-gauge atraumatic needle (Sprotte, 22GS) compared with 22-gauge traumatic needle (Quincke, 22GQ).

BACKGROUND

Diagnostic lumbar puncture (dLP) is commonly complicated by PDPH. Despite evidence to support the use of 22GS, European neurologists seem to keep using 22GQ.

METHODS

This was a randomized, double-blind study. Adults (age: 18-60 years) scheduled for dLP were included. dLP and CSF acquisition were performed in accordance with highly standardized procedures. Patients were followed up on days 2 and 7.

RESULTS

In total, 172 patients were randomized and lumbar punctured, and 21 were excluded due to wrong inclusion (n = 11), needle switch (n = 7), failed dLP (n = 1), withdrawal (n = 1), and missed follow-up (n = 1). Among the remaining 151 patients (mean age: 40.7 ± 12.4 years), 77 had dLP using 22GQ and 74 using 22GS. Incidence of PDPH among patients punctured with 22GS (18%) was significantly lower (p = .004) than among patients punctured with 22GQ (39%). Relative risk was 0.45, 95% CI 0.26-0.80. Patients with PDPH had significantly lower weight (p = .035), and there was no significant difference related to age (p = .064), sex (p = .239), height (p = .857), premorbid episodic migraine (p = .829), opening pressure (p = .117), operators (p = .148), amount of CSF removed (p = .205), or number of attempts (p = .623).

CONCLUSIONS

The use of 22GS halves the risk of PDPH compared with 22GQ. This study provides strong support to make a change in practice where traumatic needles are still in regular use.

Does post dural puncture headache exist in idiopathic intracranial hypertension? A pilot study

BACKGROUND/OBJECTIVE

Occurrence of post-dural puncture headache (PDPH) after diagnostic lumbar puncture (LP) for idiopathic intracranial hypertension (IIH) may seem very unlikely in clinical practice. Nevertheless, it has been suggested by several studies, mainly in sub-group analyses. We aimed to evaluate the prevalence of PDPH in an IIH population and determine any eventual predictive factors of PDPH occurrence.

METHODS

We conducted a retrospective multiple-center observational study. All newly diagnosed IIH patients who met the International Classification of Headache Disorders (ICHD-3) or the Dandy modified criteria were included from three different French hospitals. They all underwent LP following the same process with the same type of needle. We recorded PDPH occurring within five days after LP, as defined by ICHD-3 criteria.

RESULTS

Seventy-four IIH patients were recruited, of whom 23 (31%) presented with PDPH. Neither classical risk factors for PDPH such as body mass index, age or gender, nor cerebrospinal fluid opening pressure, or specific IIH features were associated with occurrence of PDPH.

CONCLUSION

PDPH can occur after LP in IIH patients. Clinicians should be aware of this possible event during the IIH diagnosis assessment and should not automatically reconsider IIH diagnosis. PDPH prevention using an atraumatic needle and dedicated PDPH treatment seem relevant in IIH patients.

A double-blind placebo controlled trial on effectiveness of prophylactic dexamethasone for preventing post- dural puncture headache after spinal anesthesia for cesarean section

AIM

To determine the effect of dexamethasone in reducing post-dural puncture headache (PDPH) after spinal anesthesia for cesarean section (CS).

METHODS

A double blind placebo controlled randomized trial of parturients undergoing CS under spinal anesthesia was conducted. Participants (n = 192) were randomly (1:1 ratio) given either 2mls (8 mg) of dexamethasone (n = 96) intravenously or 2mls of normal saline (n = 96) intravenously as placebo after clamping the umbilical cord. Visual analogue scale was used to assess the incidence and severity of PDPH on the first and fourth post-operative days. The primary outcome measure was incidence of PDPH while the secondary outcome measure was incidence of nausea and vomiting. Analysis was by intention-to-treat.

RESULTS

Baseline socio-demographic and clinical variables were similar between the two groups and none of the women was lost to follow up. The incidence of PDPH (8.3% vs 25.0%; p = .002) and nausea (11.5% vs 25.0%; p = .015) were significantly lower in dexamethasone group. The severity of headache in the control groups were statistically higher on the first (p < .001) and fourth (p < .001) post-operative days. .

CONCLUSION

Prophylactic dexamethasone reduces the incidence and severity of PDPH on both the first and fourth post-operative day after spinal anesthesia for CS. There was also an improvement on the incidence of nausea on the dexamethasone group compared to control.

High-flow oxygen and pro-serotonin agents for non-interventional treatment of post-dural-puncture headache

OBJECTIVE

Post dural puncture headache (PDPH) is a common complication in patients following diagnostic or therapeutic lumbar puncture, procedures requiring epidural access, and spinal surgery. Epidural blood patch (EBP), the gold standard for the treatment of this pathology requires training not provided to emergency physicians. In addition, the presence of concomitant pathology and abnormal laboratory values are contraindications to perform EBP. In presence of these limitations, we sought for a non-interventional management of PDPH utilizing high-flow oxygen and pro-serotonin agents. We reviewed the mechanism of action of this therapy METHODS: To illustrate our proposal, we report a series of twelve consecutive patients with PDPH treated with high-flow oxygen therapy at 12 L/min via a non-rebreathing mask and intravenous metoclopramide.

RESULTS

All patients were treated with this conservative therapy, no adverse reactions were observed. After the intervention, the headache resolved without further indications for PDPH.

CONCLUSION

Our series suggests that combining high-flow oxygen and pro-serotonin agents such metoclopramide in the ED might be a feasible option as effective as the invasive methods used in treating PDPH. This therapy appears to be efficient and to minimize risk, cost and side effects. It presents an easily accessible alternative that should be considered when PDPH is not a viable option.

Postdural puncture headache leads to clinical worsening of pre-existing chronic headache

The incidence of postdural puncture headache (PDPH) in relation to pre-existing chronic headache (CH) was assessed, as was the clinical course of CH, at one, three, and six months after PDPH. The study was conducted as a single center cohort prospective study that included 252 patients (105 men and 147 women), average age of 47.3 ± 15.0 years, on whom lumbar puncture (LP) was performed. PDPH was reported in 133 (52.8%) patients; CH was reported in 82 (32.5%) patients. Patients with CH were more likely to have PDPH (p = 0.003). The individual clinical type of CH did not have an effect on the incidence of PDPH (p = 0.128). Patients with PDPH had a clinical deterioration of CH three and six months after LP (p = 0.047, p = 0.027, respectively) in terms of increased headache days per month and/or incomplete efficacy of performed therapy in relation to baseline values. Six months after LP, the worsening of CH was more common in women with PDPH (OR 5,687 [95% CI: 1526-21,200], p = 0.010) and patients with a longer history of CH (OR 1064 [95% CI: 1007-1124], p = 0.027). Multivariate analysis confirmed the direct association of female sex and duration of CH and its worsening six months after PDPH (OR 4478 [95% CI: 1149-17,452], p = 0.031; OR 1448 [95% CI: 1292-1808], p = 0.022). The presented results could be significant for the prediction/differential diagnosis of PDPH in patients with CH and for the prediction/prevention of CH clinical worsening after PDPH.

Are CSF Pressure Factors Related to the Development of Post-dural Puncture Headache?

Post-dural puncture headache (PDPH) is an unfavorable situation seen in considerable number of patients even though atraumatic and small needle reduces its incidence. CSF pressures measured at the time of puncture change after CSF drainage. In the present study, we investigated relationships between CSF pressure-related factors and occurrence of PDPH. We prospectively enrolled 103 participants who underwent CSF studies for meningitis. Using a standardized protocol, CSF opening pressure (OP) and closing pressure (CP) were measured, and cerebrospinal elastance (ECS) and pressure-volume index (PVI) were investigated. Within 14 days after dural puncture, we confirmed PDPH. According to PDPH development, the CSF pressure factors and clinical variables were compared between PDPH and non-PDPH group. Of the 103 participants, 100 (97.0%) had decreased CP, 16 (15.5%) had values below 6 cmH₂O and the pressure change after dural puncture (OP-CP) was 6.1 ± 3.1 cmH₂O. PVI and ECS measured by CSF drainage were 99.8 ± 89.5 and 0.4 ± 0.2 cmH₂O/mL. Among the demographic factors, body weight was correlated with OP (r = 0.27), CP (r = 0.35), and PVI (r = 0.20). Height was weakly correlated with CP (r = 0.199) During the study period, 22 participants (21.34%) developed PDPH. None of the CSF pressure factors were significantly different between the PDPH and non-PDPH group and did not contributed to the development of PDPH. CSF pressure factors might not be related to the development of PDPH.

[Post-lumbar puncture syndrome]

This article presents a clinical case which describes some clinical aspects, risk factors, management and the prophylactic methods to prevent the post-lumbar puncture syndrome.

Post-Dural Puncture Headache is Uncommon in Young Ambulatory Surgery Patients

BACKGROUND

The incidence of post-dural puncture headache (PDPH) arising from spinal anesthesia in the general population is low. However, patients under 45 years have been shown to exhibit a higher incidence of PDPH, even with small needles.

QUESTIONS/PURPOSES

This study aimed to estimate the incidence of PDPH from a 27G pencil-point needle in ambulatory surgery patients between the ages of 15-45 years and compare incidence of PDPH by age group, sex, and history of headache.

METHODS

In this prospective cohort study, 300 patients (15-45 years old) who underwent simple knee arthroscopy under spinal anesthesia with a 27G pencil-point needle were enrolled. Verbal consent was obtained during the initial phone conversation between post-operative days (PODs) 2-5. A PDPH questionnaire was administered during this conversation and between PODs 7-10. Patients who reported a positional headache were contacted by a physician co-investigator, who determined PDPH diagnosis.

RESULTS

Five patients were excluded from analysis due to complicated operative procedures or spinal needle size. The overall PDPH incidence was 2.0% (95% CI 0.9-4.4; 6/295). PDPH incidence in 15-19-year-old patients was 16.7% (95% CI 4.7-44.8; 2/12). The crude relative risk of PDPH was 15.4 (95% CI 2.8-114.4) for patients with and without history of headache and 2.5 (95% CI 0.5-14.8) for females vs. males. Overall, 16.3% (95% CI 12.5-20.9) of patients reported post-operative, non-positional headaches.

CONCLUSIONS

There was a low overall incidence of PDPH among patients aged 15-45. Pre-planned subgroup analyses of PDPH incidence by age group revealed a high risk of PDPH among a small sample of 15-19-year-olds.

Needle gauge and tip designs for preventing post-dural puncture headache (PDPH)

BACKGROUND

Post-dural puncture headache (PDPH) is one of the most common complications of diagnostic and therapeutic lumbar punctures. PDPH is defined as any headache occurring after a lumbar puncture that worsens within 15 minutes of sitting or standing and is relieved within 15 minutes of the patient lying down. Researchers have suggested many types of interventions to help prevent PDPH. It has been suggested that aspects such as needle tip and gauge can be modified to decrease the incidence of PDPH.

OBJECTIVES

To assess the effects of needle tip design (traumatic versus atraumatic) and diameter (gauge) on the prevention of PDPH in participants who have undergone dural puncture for diagnostic or therapeutic causes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and LILACS, as well as trial registries via the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal in September 2016. We adopted the MEDLINE strategy for searching the other databases. The search terms we used were a combination of thesaurus-based and free-text terms for both interventions (lumbar puncture in neurological, anaesthesia or myelography settings) and headache.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) conducted in any clinical/research setting where dural puncture had been used in participants of all ages and both genders, which compared different tip designs or diameters for prevention of PDPH DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 70 studies in the review; 66 studies with 17,067 participants were included in the quantitative analysis. An additional 18 studies are awaiting classification and 12 are ongoing. Fifteen of the 18 studies awaiting classification mainly correspond to congress summaries published before 2010, in which the available information does not allow the complete evaluation of all their risks of bias and characteristics. Our main outcome was prevention of PDPH, but we also assessed the onset of severe PDPH, headache in general and adverse events. The quality of evidence was moderate for most of the outcomes mainly due to risk of bias issues. For the analysis, we undertook three main comparisons: 1) traumatic needles versus atraumatic needles; 2) larger gauge traumatic needles versus smaller gauge traumatic needles; and 3) larger gauge atraumatic needles versus smaller gauge atraumatic needles. For each main comparison, if data were available, we performed a subgroup analysis evaluating lumbar puncture indication, age and posture.For the first comparison, the use of traumatic needles showed a higher risk of onset of PDPH compared to atraumatic needles (36 studies, 9378 participants, risk ratio (RR) 2.14, 95% confidence interval (CI) 1.72 to 2.67, I2 = 9%).In the second comparison of traumatic needles, studies comparing various sizes of large and small gauges showed no significant difference in effects in terms of risk of PDPH, with the exception of one study comparing 26 and 27 gauge needles (one study, 658 participants, RR 6.47, 95% CI 2.55 to 16.43).In the third comparison of atraumatic needles, studies comparing various sizes of large and small gauges showed no significant difference in effects in terms of risk of PDPH.We observed no significant difference in the risk of paraesthesia, backache, severe PDPH and any headache between traumatic and atraumatic needles. Sensitivity analyses of PDPH results between traumatic and atraumatic needles omitting high risk of bias studies showed similar results regarding the benefit of atraumatic needles in the prevention of PDPH (three studies, RR 2.78, 95% CI 1.26 to 6.15; I2 = 51%).

AUTHORS' CONCLUSIONS

There is moderate-quality evidence that atraumatic needles reduce the risk of post-dural puncture headache (PDPH) without increasing adverse events such as paraesthesia or backache. The studies did not report very clearly on aspects related to randomization, such as random sequence generation and allocation concealment, making it difficult to interpret the risk of bias in the included studies. The moderate quality of the evidence for traumatic versus atraumatic needles suggests that further research is likely to have an important impact on our confidence in the estimate of effect.

Altered functional connectivity of the marginal division in migraine: a resting-state fMRI study

BACKGROUND

The marginal division of neostriatum (MrD) is a flat, pan-shaped zone between the neostriatum and the globus pallidus, and previous documents demonstrated that it was involved in the modulation of pain. The aim of this study is to investigate the roles of the MrD of the human brain in the chronicization migraine using resting state functional magnetic resonance imaging (rs-fMRI).

METHODS

Conventional MRI, 3D structure images, and rs-fMRI were performed in 18 patients with episodic migraines (EM), 16 patients with chronic migraine (CM), 44 patients with medication overuse headache plus chronic migraine (MOH + CM), and 32 normal controls (NC). MrD was defined using manual delineation on structural images, and was selected as the seed to calculate the functional connectivity (FC).

RESULTS

Compared with the NC group, the decreased FC of MrD was observed in the EM and CM groups, and increased FC of MrD was demonstrated in all patient groups. Compared with the EM group, the decreased FC of MrD was revealed in the CM and MOH + CM groups, and the increased FC occurred only in the CM group. Increased FC of MrD alone was observed in the MOH + CM group compared with that in the CM group.

CONCLUSION

This study confirmed the double neuromodulation network of MrD in pain modulation and migraine chronicization; however, the mechanism requires further investigation.

Continuous epidural pumping of saline contributes to prevent and treat postdural puncture headache

STUDY OBJECTIVE

Postdural puncture headache (PDPH) is the most common symptom of accidental dural puncture, a frequent complication of intraspinal anesthesia. We developed a postoperative intervention technique to prevent and treat PDPH in accidental dural puncture patients, including epidural pumping of saline. This retrospective study aimed to retrospectively evaluate this new technique for PDPH prevention and treatment.

DESIGN

Retrospective study.

SETTING

Beijing Obstetrics and Gynecology Hospital affiliated to the Capital Medical University, between January 2006 and December 2012.

PATIENTS

Eighty-seven cases undergoing intraspinal anesthesia were assessed.

INTERVENTIONS

Of these patients, 68 cases had successful repuncture and were assigned to group A (epidural filling group, n=68), receiving continuous epidural pumping of 0.9% NS (150mL) at a rate of 6mL/h; the remaining cases were assigned to group B (conservative therapy group, n=19).

MEASUREMENTS

Age, height, and body weight were collected, and postoperative headache was assessed using a visual analog scale.

MAIN RESULTS

Of 68 patients in group A, 49 (72.1%) developed PDPH, whereas all in group B developed PDPH (P=.009). In addition, all patients showed PDPH within 3days after surgery regardless of treatment group. However, a statistically significant difference was obtained for PDPH duration between groups A and B (P<.001). Multivariate logistic regression analysis showed that frequency of epidural puncture and continuous epidural pumping of saline were significant risk factors for PDPH.

CONCLUSIONS

Our data indicated that application of 6mL/h saline effectively contributes to PDPH management, and its clinical application should be broadened.

Posture and fluids for preventing post-dural puncture headache

BACKGROUND

Post-dural puncture headache (PDPH) is a common complication of lumbar punctures. Several theories have identified the leakage of cerebrospinal fluid (CSF) through the hole in the dura as a cause of this side effect. It is therefore necessary to take preventive measures to avoid this complication. Prolonged bed rest has been used to treat PDPH once it has started, but it is unknown whether prolonged bed rest can also be used to prevent it. Similarly, the value of administering fluids additional to those of normal dietary intake to restore the loss of CSF produced by the puncture is unknown. This review is an update of a previously published review in the Cochrane Database of Systematic Reviews (Issue 7, 2013) on "Posture and fluids for preventing post-dural puncture headache".

OBJECTIVES

To assess whether prolonged bed rest combined with different body and head positions, as well as administration of supplementary fluids after lumbar puncture, prevent the onset of PDPH in people undergoing lumbar puncture for diagnostic or therapeutic purposes.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and LILACS, as well as trial registries up to February 2015.

SELECTION CRITERIA

We identified randomized controlled trials that compared the effects of bed rest versus immediate mobilization, head-down tilt versus horizontal position, prone versus supine positions during bed rest, and administration of supplementary fluids versus no/less supplementation, as prevention measures for PDPH in people who have undergone lumbar puncture.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies for eligibility through the web-based software EROS (Early Review Organizing Software). Two different review authors independently assessed risk of bias using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We resolved any disagreements by consensus. We extracted data on cases of PDPH, severe PDPH, and any headache after lumbar puncture and performed intention-to-treat analyses and sensitivity analyses by risk of bias. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and created a 'Summary of findings' table.

MAIN RESULTS

We included 24 trials with 2996 participants in this updated review. The number of participants in each trial varied from 39 to 382. Most of the included studies compared bed rest versus immediate mobilization, and only two assessed the effects of supplementary fluids versus no supplementation. We judged the overall risk of bias of the included studies as low to unclear. The overall quality of evidence was low to moderate, downgraded because of the risk of bias assessment in most cases. The primary outcome in our review was the presence of PDPH.There was low quality evidence for an absence of benefits associated with bed rest compared with immediate mobilization on the incidence of severe PDPH (risk ratio (RR) 0.98; 95% confidence interval (CI) 0.68 to 1.41; participants = 1568; studies = 9) and moderate quality evidence on the incidence of any headache after lumbar puncture (RR 1.16; 95% CI 1.02 to 1.32; participants = 2477; studies = 18). Furthermore, bed rest probably increased PDPH (RR 1.24; 95% CI 1.04 to 1.48; participants = 1519; studies = 12) compared with immediate mobilization. An analysis restricted to the most methodologically rigorous trials (i.e. those with low risk of bias in allocation method, missing data and blinding of outcome assessment) gave similar results. There was low quality evidence for an absence of benefits associated with fluid supplementation on the incidence of severe PDPH (RR 0.67; 95% CI 0.26 to 1.73; participants = 100; studies = 1) and PDPH (RR 1; 95% CI 0.59 to 1.69; participants = 100; studies = 1), and moderate quality evidence on the incidence of any headache after lumbar puncture (RR 0.94; 95% CI 0.66 to 1.34; participants = 200; studies = 2). We did not expect other adverse events and did not assess them in this review.

AUTHORS' CONCLUSIONS

Since the previous version of this review, we found one new study for inclusion, but the conclusion remains unchanged. We considered the quality of the evidence for most of the outcomes assessed in this review to be low to moderate. As identified studies had shortcomings on aspects related to randomization and blinding of outcome assessment, we therefore downgraded the quality of the evidence. In general, there was no evidence suggesting that routine bed rest after dural puncture is beneficial for the prevention of PDPH onset. The role of fluid supplementation in the prevention of PDPH remains unclear.

Drug therapy for treating post-dural puncture headache

BACKGROUND

This is an updated version of the original Cochrane review published in Issue 8, 2011, on 'Drug therapy for treating post-dural puncture headache'.Post-dural puncture headache (PDPH) is the most common complication of lumbar puncture, an invasive procedure frequently performed in the emergency room. Numerous pharmaceutical drugs have been proposed to treat PDPH but there are still some uncertainties about their clinical effectiveness.

OBJECTIVES

To assess the effectiveness and safety of drugs for treating PDPH in adults and children.

SEARCH METHODS

The searches included the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 6), MEDLINE and MEDLINE in Process (from 1950 to 29 July 2014), EMBASE (from 1980 to 29 July 2014) and CINAHL (from 1982 to July 2014). There were no language restrictions.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) assessing the effectiveness of any pharmacological drug used for treating PDPH. Outcome measures considered for this review were: PDPH persistence of any severity at follow-up (primary outcome), daily activity limited by headache, conservative supplementary therapeutic option offered, epidural blood patch performed, change in pain severity scores, improvements in pain severity scores, number of days participants stay in hospital, any possible adverse events and missing data.

DATA COLLECTION AND ANALYSIS

Review authors independently selected studies, assessed risk of bias and extracted data. We estimated risk ratios (RR) for dichotomous data and mean differences (MD) for continuous outcomes. We calculated a 95% confidence interval (CI) for each RR and MD. We did not undertake meta-analysis because the included studies assessed different sorts of drugs or different outcomes. We performed an intention-to-treat (ITT) analysis.

MAIN RESULTS

We included 13 small RCTs (479 participants) in this review (at least 274 participants were women, with 118 parturients after a lumbar puncture for regional anaesthesia). In the original version of this Cochrane review, only seven small RCTs (200 participants) were included. Pharmacological drugs assessed were oral and intravenous caffeine, subcutaneous sumatriptan, oral gabapentin, oral pregabalin, oral theophylline, intravenous hydrocortisone, intravenous cosyntropin and intramuscular adrenocorticotropic hormone (ACTH).Two RCTs reported data for PDPH persistence of any severity at follow-up (primary outcome). Caffeine reduced the number of participants with PDPH at one to two hours when compared to placebo. Treatment with caffeine also decreased the need for a conservative supplementary therapeutic option.Treatment with gabapentin resulted in better visual analogue scale (VAS) scores after one, two, three and four days when compared with placebo and also when compared with ergotamine plus caffeine at two, three and four days. Treatment with hydrocortisone plus conventional treatment showed better VAS scores at six, 24 and 48 hours when compared with conventional treatment alone and also when compared with placebo. Treatment with theophylline showed better VAS scores compared with acetaminophen at two, six and 12 hours and also compared with conservative treatment at eight, 16 and 24 hours. Theophylline also showed a lower mean "sum of pain" when compared with placebo. Sumatriptan and ACTH did not show any relevant effect for this outcome.Theophylline resulted in a higher proportion of participants reporting an improvement in pain scores when compared with conservative treatment.There were no clinically significant drug adverse events.The rest of the outcomes were not reported by the included RCTs or did not show any relevant effect.

AUTHORS' CONCLUSIONS

None of the new included studies have provided additional information to change the conclusions of the last published version of the original Cochrane review. Caffeine has shown effectiveness for treating PDPH, decreasing the proportion of participants with PDPH persistence and those requiring supplementary interventions, when compared with placebo. Gabapentin, hydrocortisone and theophylline have been shown to decrease pain severity scores. Theophylline has also been shown to increase the proportion of participants that report an improvement in pain scores when compared with conventional treatment.There is a lack of conclusive evidence for the other drugs assessed (sumatriptan, adrenocorticotropic hormone, pregabalin and cosyntropin).These conclusions should be interpreted with caution, due to the lack of information to allow correct appraisal of risk of bias, the small sample sizes of the studies and also their limited generalisability, as nearly half of the participants were postpartum women in their 30s.

Intracranial pressure in unresponsive chronic migraine

To assess the prevalence and possible pathogenetic involvement of raised intracranial pressure in patients presenting with unresponsive chronic migraine (CM), we evaluated the intracranial opening pressure (OP) and clinical outcome of a single cerebrospinal fluid withdrawal by lumbar puncture in 44 consecutive patients diagnosed with unresponsive chronic/transformed migraine and evidence of sinus stenosis at magnetic resonance venography. The large majority of patients complained of daily or near-daily headache. Thirty-eight (86.4 %) had an OP >200 mmH₂O. Lumbar puncture-induced normalization of intracranial pressure resulted in prompt remission of chronic pain in 34/44 patients (77.3 %); and an episodic pattern of headache was maintained for 2, 3 and 4 months in 24 (54.6 %), 20 (45.4 %) and 17 (38.6 %) patients, respectively. The medians of overall headache days/month and of disabling headache days/month significantly decreased (p < 0.0001) at each follow-up versus baseline. Despite the absence of papilledema, 31/44 (70.5 %) patients fulfilled the ICHD-II criteria for “Headache attributed to Intracranial Hypertension”. Our findings indicate that most patients diagnosed with unresponsive CM in specialized headache clinics may present an increased intracranial pressure involved in the progression and refractoriness of pain. Moreover, a single lumbar puncture with cerebrospinal fluid withdrawal results in sustained remission of chronic pain in many cases. Prospective controlled studies are needed before this procedure can be translated into clinical practice. Nonetheless, we suggest that intracranial hypertension without papilledema should be considered in all patients with almost daily migraine pain, with evidence of sinus stenosis, and unresponsive to medical treatment referred to specialized headache clinics.

Histamine in migraine and brain

BACKGROUND

Histamine has been studied in both health and disease since the initial description a century ago. With its vasodilative effect, it was suggested early on to be involved in the pathophysiology of migraine. Over the past 25 years, much has been learned about histamine as a neurotransmitter in the central nervous system. The role of this neurotransmitter system in migraine has not been previously reviewed.

OBJECTIVE

Discuss a potential role of the brain histaminergic system in migraine.

METHODS

Unstructured literature search with a no specific hypothesis-driven approach.

RESULTS

There is substantial evidence that systemically given histamine may elicit, maintain, and aggravate headache. The mechanisms for this are not known, and histamines do not penetrate the blood-brain barrier (BBB). However, circulating histamine may influence hypothalamic activity via the circumventricular organs that lack BBB. In the rat, prolonged activation of meningeal nociceptors induced by dural mast cell degranulation has been observed. Subcutaneous injections of N-alpha-methyl histamine, a catabolite of histamine with high affinity to the histamine H3 receptor, probably have some migraine preventive effect. A negative feedback on histamine release from mast cells in proximity to C-fiber endings has been a postulated mechanism. Most antihistamines have shown to be ineffective as acute medication for migraine. Two centrally acting potent H1 receptor antagonists (cinnarizine and cyproheptadine) have been reported to be efficacious in preventing migraine. However, the proof for this is limited, and their efficacy has been ascribed other actions than the antihistaminergic. In general, lack of specificity and side effects limit the potential use of centrally acting H1 and H2 antagonists. Brain histamine is synthesized by neurons that are restricted to the posterior basal hypothalamus, more specific to the tuberomamillary nucleus (TMN), and that project practically to the whole central nervous system. The posterior hypothalamus is a suspected locus in quo in several primary headaches. Recently, a positron emission tomography study performed in the prodromal phase of migraine attacks supported the idea of initial involvement of this area. In another recent study, the thalamic nuclei receiving trigeminal output was also shown to have direct connections with the ventral TMN. The central histaminergic system plays an important role in the complex sleep-wake cycle, promoting cortical excitability during wakening and attention, and it consolidates the wake state. The period of the day, in the evenings and during the night, when there is reduced susceptibility for migraine attacks corresponds with less central histaminergic firing. Activation of both the H3 and the H4 receptor promotes inhibitory actions on neurons. The H3 receptor causes autoinhibition of the histaminergic neurons themselves, and centrally acting H3 receptor agonist prodrugs have shown to both inhibit neurogenic inflammation in dura, to induce sleep, and to produce antinociception. There are no registered ongoing studies on H3 and H4 receptor ligands in migraine.

CONCLUSION

The role of the central histaminergic system in migraine is largely unexplored, but findings from preclinical research may be linked to several aspects of the disorder. The histaminergic system of the brain may play an important role, especially in the initial phase of an attack, and histamine H3 and H4 receptor ligands may potentially have migraine prophylactic properties. However, the basis for this is still circumstantial, and the evidence is lacking.

Lumbar puncture-related cerebrospinal fluid leakage on magnetic resonance myelography: is it a clinically significant finding?

Background

Post-dural puncture headache (PDPH) due to excessive cerebrospinal fluid (CSF) leakage is a well-known complication of lumbar puncture. Although various factors, especially the type of spinal needle, have been demonstrated to be associated with PDPH, the clinical implications of CSF leakage detected on magnetic resonance myelography (MRM) images remain unclear. The objective of this case–control study was to evaluate the association between radiologically visualized CSF leakage and PDPH.

Methods

Clinical data including patients’ age and gender, types of spinal needle, duration of bed rest, interval between lumbar puncture procedures and MRM studies, and incidence of PDPH were compared between patients who were radiologically-positive and -negative for CSF leakage.

Results

Of the 22 patients with definite CSF leakage on MRM images, most were asymptomatic (86%, 19/22). The remaining three patients, who were suffering from PDPH, only complained of headaches and were treated conservatively. In a review of patients’ clinical data, there were no significant differences in any parameter including the incidence of PDPH between the 22 patients who were radiologically-positive for CSF leakage and the 31 radiologically-negative patients.

Conclusion

The significance of radiologically visualized CSF leakage should not be overestimated, as most such incidents are not associated with PDPH and do not require any treatment.

Posture and fluids for preventing post-dural puncture headache

BACKGROUND

Post-dural puncture headache (PDPH) is a common complication of lumbar punctures. Several theories have identified the leakage of cerebrospinal fluid (CSF) through the hole in the dura as a cause of this side effect. Therefore, it is necessary to take preventive measures to avoid this complication. Prolonged bed rest has been used as a therapeutic measure once PDPH has started, but it is unknown if it can be also be used to prevent it. Similarly, the value of administering fluids additional to those of normal dietary intake to restore the loss of CSF produced by the puncture is unknown.

OBJECTIVES

To assess whether prolonged bed rest combined with different body and head positions, as well as administration of supplementary fluids after lumbar puncture, prevent the onset of PDPH in people undergoing lumbar puncture for diagnostic or therapeutic purposes.

SEARCH METHODS

We searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE, and LILACS up to June 2013.

SELECTION CRITERIA

We identified randomized controlled trials (RCTs) that compared the effects of bed rest versus early/immediate mobilization, head-down tilt versus horizontal position, prone versus supine positions during bed rest, and administration of supplementary fluids versus no/less supplementation, as prevention measures for PDPH in people who have undergone lumbar puncture.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies for eligibility through the web-based software EROS (Early Review Organizing Software). Two different review authors independently assessed risk of bias using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We solved any disagreements by consensus. We extracted data on cases of PDPH, severe PDPH, and any headache after lumbar puncture and performed intention-to-treat analyses and sensitivity analyses by risk of bias.

MAIN RESULTS

We included 23 trials (2477 participants) in this review. There was no beneficial effect associated with bed rest compared with immediate mobilization on the incidence of PDPH (risk for bed rest 26.4%; risk for mobilization 20.5%; risk ratio (RR) 1.30; 95% confidence interval (CI) 1.09 to 1.55), severe PDPH (risk for bed rest 10.6%; risk for mobilization 10.7%; RR 1.00; 95% CI 0.75 to 1.32), and presence of any headache after lumbar puncture (risk for bed rest 33.6%; risk for mobilization 28.6%; RR 1.18; 95% CI 1.05 to 1.32). Analyses restricted to the most methodologically rigorous trials gave similar results. Likewise, the two trials that assessed fluid supplementation did not find this preventive measure to be useful in the prevention of PDPH.

AUTHORS' CONCLUSIONS

There is no evidence from RCTs that suggests that routine bed rest after dural puncture is beneficial for the prevention of PDPH onset. The role of fluid supplementation in the prevention of PDPH remains unclear.

Drug therapy for preventing post-dural puncture headache

BACKGROUND

Post-dural (post-lumbar or post-spinal) puncture headache (PDPH) is one of the most common complications of diagnostic, therapeutic or inadvertent lumbar punctures. Many drug options have been used to prevent headache in clinical practice and have also been tested in some clinical studies, but there are still some uncertainties about their clinical effectiveness.

OBJECTIVES

To assess the effectiveness and safety of drugs for preventing PDPH in adults and children.

SEARCH METHODS

The search strategy included the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2012, Issue 5), MEDLINE (from 1950 to May 2012), EMBASE (from 1980 to May 2012) and CINAHL (from 1982 to June 2012). There was no language restriction.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) that assessed the effectiveness of any drug used for preventing PDPH.

DATA COLLECTION AND ANALYSIS

Review authors independently selected studies, assessed risks of bias and extracted data. We estimated risk ratios (RR) for dichotomous data and mean differences (MD) for continuous outcomes. We calculated a 95% confidence interval (CI) for each RR and MD. We did not undertake meta-analysis because participants' characteristics or assessed doses of drugs were too different in the included studies. We performed an intention-to-treat (ITT) analysis.

MAIN RESULTS

We included 10 RCTs (1611 participants) in this review with a majority of women (72%), mostly parturients (women in labour) (913), after a lumbar puncture for regional anaesthesia. Drugs assessed were epidural and spinal morphine, spinal fentanyl, oral caffeine, rectal indomethacin, intravenous cosyntropin, intravenous aminophylline and intravenous dexamethasone.All the included RCTs reported data on the primary outcome, i.e. the number of participants affected by PDPH of any severity after a lumbar puncture. Epidural morphine and intravenous cosyntropin reduced the number of participants affected by PDPH of any severity after a lumbar puncture when compared to placebo. Also, intravenous aminophylline reduced the number of participants affected by PDPH of any severity after a lumbar puncture when compared to no intervention, while intravenous dexamethasone increased it. Spinal morphine increased the number of participants affected by pruritus when compared to placebo, and epidural morphine increased the number of participants affected by nausea and vomiting when compared to placebo. Oral caffeine increased the number of participants affected by insomnia when compared to placebo.The remainder of the interventions analysed did not show any relevant effect for any of the outcomes.None of the included RCTs reported the number of days that patients stayed in hospital.

AUTHORS' CONCLUSIONS

Morphine and cosyntropin have shown effectiveness for reducing the number of participants affected by PDPH of any severity after a lumbar puncture, when compared to placebo, especially in patients with high risk of PDPH, such as obstetric patients who have had an inadvertent dural puncture. Aminophylline also reduced the number of participants affected by PDPH of any severity after a lumbar puncture when compared to no intervention in patients undergoing elective caesarean section. Dexamethasone increased the risk of PDPH, after spinal anaesthesia for caesarean section, when compared to placebo. Morphine also increased the number of participants affected by adverse events (pruritus and nausea and vomiting)There is a lack of conclusive evidence for the other drugs assessed (fentanyl, caffeine, indomethacin and dexamethasone).These conclusions should be interpreted with caution, owing to the lack of information, to allow correct appraisal of risk of bias and the small sample sizes of studies.

Postdural puncture headache in migraineurs and nonheadache subjects: a prospective study

OBJECTIVES

To prospectively assess 1) the incidence and duration of postdural puncture headache (PDPH) in migraineurs and healthy subjects; 2) the associated risk factors; and 3) the risk of getting a migraine attack shortly before or after lumbar puncture (LP).

METHODS

As part of an extensive biochemical migraine research program, we assessed the occurrence, duration, and characteristics of PDPH in 160 migraineurs and 53 age- and sex-matched healthy controls. In addition, we evaluated potential risk factors for PDPH as well as the risk of developing a migraine attack before or after LP.

RESULTS

In total, 64 of 199 subjects (32.2%) developed PDPH. Young age, low body mass index, severe headache immediately after LP, and sitting sampling position, but not being a migraineur, increased the risk of PDPH (all p < 0.05). Duration of PDPH was prolonged by history of depression, sitting sampling position, high perceived stress during the LP procedure, and multiple LP efforts (all p < 0.05). Migraine attacks were less likely to occur before or shortly after LP.

CONCLUSIONS

Migraineurs are not at increased risk of developing PDPH. PDPH duration is similar in migraineurs and age- and sex-matched controls. LP does not trigger migraine attacks, and the stress of an upcoming LP might even have a protective effect against onset of migraine attacks.

Post-lumbar puncture headache

BACKGROUND

Headache is a complication of lumbar puncture that has been known for more than a hundred years. The aim of this paper is to provide an overview of the incidence and symptoms of, the risk factors for and the treatment of this type of headache.

METHOD

The article is based on a literature search in PubMed for studies on headache after lumbar puncture followed by discretionary selection of publications.

RESULTS

Post-dural puncture headache (PDPH) is characterised by the occurrence of a headache with a significant orthostatic component within 5 days of a lumbar puncture. The incidence depends on a number of factors. Younger women with a previous history of headaches appear to be at highest risk. The incidence can be significantly reduced by using a thin lumbar puncture needle with an atraumatic tip. The condition is self-limiting and harmless, but leads to significant morbidity. Caffeine alleviates the symptoms and reduces the course of the illness. When bed rest and caffeine prove ineffective, an epidural blood patch works well for the majority, but there is no consensus on when such treatment should be offered.

INTERPRETATION

Headache frequently occurs after lumbar puncture. There is substantial evidence for recommending the use of a thin, atraumatic needle to reduce the incidence. For practical reasons, a needle thinner than 22 G is not suitable for diagnostic lumbar puncture.

Incidence of post-dural puncture headache in research volunteers

OBJECTIVE

To determine the frequency and risk factors of post-dural puncture headache (PDPH) in research volunteers.

BACKGROUND

Despite increasing interest in measuring cerebrospinal fluid (CSF) biomarkers to investigate disease pathogenesis and diagnosis, previous case series have evaluated lumbar puncture (LP) safety only in clinical care. PDPH is a common complication after LP.

METHODS

We determined the frequency of PDPH in neurologically unselected HIV seropositive and seronegative adults volunteering for research, as well as the variables associated with the development of PDPH. Variables studied were body mass index (BMI), HIV serostatus, volume of CSF removed, number of previous LPs, use of pre-medication, LP position, lumbar space, number of needle passes, whether or not aspiration was used, CSF white blood cell counts, CSF red blood cell counts, CD4 count, CD4 nadir, CSF HIV viral load, plasma HIV viral load, and race.

RESULTS

Of 675 LPs performed over 1 year, headache developed in 38 (5.6%; 95% CI 4.2, 7.1). Most PDPH (92%) resolved spontaneously or with conservative medical management; 3 required epidural blood patch. Greater headache risk was associated with lower BMI (BMI ≤25 vs >25) (OR 3.3; CI 95% 1.5, 7.0; P = .001) and less prior LP experience (previous LPs ≤2 vs >2) (OR 2.1; CI 95% 1.1, 4.1; P = .03). PDPH was not significantly (P > .05) related to HIV serostatus, CSF volume, or gender.

CONCLUSION

In this study, where tolerance to risk was low because LPs were done for research rather than clinical purposes and healthy controls were included, adverse effects were mild and self-limited.

Drug therapy for treating post-dural puncture headache

BACKGROUND

Post-dural puncture headache (PDPH) is the most common complication of lumbar puncture, an invasive procedure frequently performed in the emergency room. Numerous pharmaceutical drugs have been proposed to treat PDPH but there are still some uncertainties about their clinical effectiveness.

OBJECTIVES

To assess the effectiveness and safety of drugs for treating PDPH in adults and children.

SEARCH STRATEGY

The search strategy included the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2011, Issue 2), MEDLINE (from 1950 to June 2011), EMBASE (from 1980 to June 2011) and CINAHL (from 1982 to June 2011). There was no language restriction.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) assessing the effectiveness of any pharmacological drug used for treating PDPH.

DATA COLLECTION AND ANALYSIS

Review authors independently selected studies, assessed risks of bias and extracted data. We estimated risk ratios (RR) for dichotomous data and mean differences (MD) for continuous outcomes. We calculated a 95% confidence interval (CI) for each RR and MD. We did not undertake meta-analysis because the included studies assessed different sorts of drugs or different outcomes. We performed an intention-to-treat (ITT) analysis.

MAIN RESULTS

We included seven RCTs (200 participants) in this review (between 88% and 90.5% were women; mostly parturients (84% to 87%) after a lumbar puncture for a regional anaesthesia). Pharmacological drugs assessed were oral and intravenous caffeine, subcutaneous sumatriptan, oral gabapentin, oral theophylline, intravenous hydrocortisone and intramuscular adrenocorticotropic hormone (ACTH).One RCT reported data about PDPH persistence of any severity at follow up (primary outcome); caffeine reduced the number of participants with PDPH at one to two hours when compared to placebo. Treatment with caffeine also decreased the need for a conservative supplementary therapeutic option. Treatment with gabapentin versus placebo reported better visual analogue scale (VAS) scores after one, two, three and four days; treatment with hydrocortisone plus conventional treatment showed better VAS scores than conventional treatment alone at six, 24 and 48 hours and treatment with theophylline showed a lower mean "sum of pain" when compared with placebo. Sumatriptan and ACTH did not show any relevant effect for this outcome.There were no clinically significant drug adverse events.The rest of the outcomes were not reported by the RCTs or did not show any relevant effect.

AUTHORS' CONCLUSIONS

Caffeine has shown effectiveness for treating PDPH, decreasing the proportion of participants with PDPH persistence and those requiring supplementary interventions, when compared with placebo. Gabapentin, theophylline and hydrocortisone have also shown a decrease in pain severity scores when compared with placebo or conventional care.There is a lack of conclusive evidence for the other drugs assessed (sumatriptan and ACTH).These conclusions should be interpreted with caution, due to the lack of information to allow correct appraisal of risk of bias, the small sample sizes of studies and also the limited generalisability, as most participants were post-partum women in their 30s.

Post-dural puncture headache: part I diagnosis, epidemiology, etiology, and pathophysiology

Post-dural puncture headache (PDPH) is a frequent complication of dural puncture whether performed for diagnostic purposes or accidentally, as a complication of anesthesia. Because both procedures are common, clinicians interested in headache should be familiar with this entity. The differential diagnosis of PDPH is broad and includes other complications of dural puncture as well as headaches attributable to the condition which lead to the procedure. The patterns of development of PDPH depend on a number of procedure- and nonprocedure-related risk factors. Knowledge of procedure-related factors supports interventions designed to reduce the incidence of PDPH. Finally, despite best preventive efforts, PDPH may still occur and be associated with significant morbidity. Therefore, it is important to know the management and prognosis of this disorder. In this review, we will highlight diagnosis and clinical characteristics of PDPH, differential diagnosis, frequency, and risk factors as well as pathophysiology of PDPH.

Lumbar puncture and post-dural puncture headaches: implications for the emergency physician

Lumbar puncture is a diagnostic procedure commonly performed by emergency physicians. Post-dural puncture headaches occur frequently after this procedure and can be associated with significant morbidity and, occasionally, even death. There is also a lot of variation in how post-dural puncture headaches are treated once they occur. This article seeks to examine the science behind post-dural puncture headaches, their prevention and treatment.

Dura-arachnoid lesions produced by 22 gauge Quincke spinal needles during a lumbar puncture

AIMS

The dural and arachnoid hole caused by lumbar puncture needles is a determining factor in triggering headaches. The aim of this study is to assess the dimensions and morphological features of the dura mater and arachnoids when they are punctured by a 22 gauge Quincke needle having its bevel either in the parallel or in the transverse position.

METHODS

Fifty punctures were made with 22 gauge Quincke needles in the dural sac of four fresh cadavers using an "in vitro" model especially designed for this purpose. The punctures were performed by needles with bevels parallel or perpendicular to the spinal axis and studied under scanning electron microscopy.

RESULTS

Thirty five of the 50 punctures done by Quincke needles (19 in the external surface and 16 in the internal) were used for evaluation. When the needle was inserted with its bevel parallel to the axis of the dural sac (17 of 35), the size of the dura-arachnoid lesion was 0.032 mm(2) in the epidural surface and 0.037 mm(2) in the subarachnoid surface of the dural sac. When the needle's bevel was perpendicular to the axis (18 of 35) the measurement of the lesion size was 0.042 mm(2) for the external surface and 0.033 mm(2) for the internal. There were no statistical significant differences between these results.

CONCLUSIONS

It is believed that the reported lower frequency of postdural puncture headache when the needle is inserted parallel to the cord axis should be explained by some other factors besides the size of the dura-arachnoid injury.

Post-dural puncture related complications after diagnostic lumbar puncture, myelography and spinal anaesthesia

OBJECTIVES

This study was conducted to investigate complications after dural puncture.

MATERIAL AND METHODS

A 15 months' prospective observation study of routine clinical practice with dural puncture at a university hospital was conducted. Quincke spinal needles 0.90 to 1.0 mm O.D. (20-19 g) were used for diagnostic lumbar puncture, 0.70 mm O.D. (22 g) for myelography and 0.40 to 0.50 mm O.D. (27-25 g) for spinal anaesthesia. A questionnaire about post-puncture discomfort was given to the patients, to be returned after 1 week.

RESULTS

Of 679 questionnaires 537 (79.1%) were returned. Discomfort was experienced by 53.8% of the patients, most often after diagnostic lumbar puncture and myelography. The difference in incidence of headache after diagnostic lumbar puncture and myelography compared with spinal anaesthesia were 27.9% (95% CI: 18.6 to 37.2) and 18.3% (95% CI: 9.1 to 27.5).

CONCLUSION

Small diameter and atraumatic spinal needles will reduce patients' discomfort after dural puncture.

Complications of lumbar puncture

This article reviews historical aspects and the following complications of lumbar puncture: cerebral and spinal herniation, postdural puncture headache, cranial neuropathies, nerve root irritation, low back pain, stylet associated problems, infections, and bleeding complications. The incidence of postdural puncture headache can be greatly reduced by pointing the face of the bevel in the direction of the patient's side, replacing the stylet and rotating the needle 90;dg before withdrawing the needle, and using the Sprotte atraumatic needle, especially in high risk patients.